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A Michigan senator has asked four emergency department staffing firms and the three private equity companies that own them for more information about their business practices following concerns raised by emergency physicians.

Sen. Gary Peters (D-Mich.), chair of the Homeland Security and Governmental Affairs Committee, asked for information from Blackstone, KKR, and Apollo Global Management and their respective staffing firms TeamHealth, Envision Healthcare, US Acute Care Solutions (USACS), and Lifepoint Health.

Peters wants to know more about business operations, staffing decisions, patient care, and safety at emergency departments across the country, following interviews by his office with more than 40 emergency physicians who raised significant concerns about patient care at private equity-owned hospitals and staffing companies.

They also worried about their ability to provide care in the event of a major emergency, such as a mass casualty event, terrorist attack, or future pandemic, according to a .

"I am concerned that our nation's largest emergency medicine staffing companies may be engaging in cost-saving measures at the expense of patient safety and care, which could put our nation's emergency preparedness at risk," Peters said in the statement.

In each of the four letters, addressed to the CEOs of the companies, Peters noted that while many of these issues "are not limited to private equity, they are exacerbated by the private equity business model, which hinges on highly leveraged debt, little equity, and the need to obtain outsized returns within a limited time."

He added that data on private equity ownership of physician staffing firms is "largely nontransparent."

The letters said that the four largest staffing firms in emergency medicine are owned or controlled by private equity companies -- which is problematic in light of recent financial troubles among those companies. Envision filed for bankruptcy last May, and TeamHealth has a payment of over a billion dollars due this year, the letters stated. In addition, USACS is facing a forced sale if it is unable to pay its private equity investors by 2026, according to the letters.

Another private equity-owned staffing company, American Physician Partners, abruptly shuttered in July 2023 and filed for bankruptcy 2 months later, the letters added.

These companies ran into financial troubles following the enactment of the No Surprises Act, which ended the practice of "surprise billing" or balance billing. Peters said Envision and TeamHealth engaged in balance billing for many years.

The letters follow discussions between Peters' office and the American Academy of Emergency Medicine and Take Medicine Back, two physician organizations that have long decried the impact of private equity and business concerns on the practice of medicine.

Mitch Li, MD, founder of Take Medicine Back, told MedPage Today in an email that Peters' office was "compelled by the gravity and substantiveness of our concerns, and the implications for the country's readiness (or lack thereof) for disaster preparedness -- man-made, natural, terrorist, pandemic, etc."

"Although they [Peters' office] fully recognize that the problems affect all of the profession -- all of healthcare -- and that they are not limited to the emergency department, the ED is where all other failures of the broken system end up," Li added.

He said investigators from Peters' office have been "diligent in following up with us, and following leads across the country."

Leah Davis, DO, a Michigan radiologist who is on the advisory board of Take Medicine Back, noted in an email that Peters' federal investigation is happening as the Michigan State Medical Society and the Michigan Osteopathic Association asked for an investigation into violations of Michigan's Corporate Practice of Medicine (CPoM) law by the state's attorney general.

Also, a union of emergency physicians in Michigan is "on the brink of a strike against TeamHealth," she said.

"The actions were not coordinated," Davis said, "but the fact that they are occurring simultaneously is evidence of how widespread and problematic CPoM has become."

Concerns about private equity's impact on healthcare in Michigan came to a head last year when emergency physicians and other clinicians contracted by TeamHealth to work at Ascension St. John Hospital in Detroit formed a union, the Greater Detroit Association of Emergency Physicians.

Peters' and its private equity owner Blackstone highlighted St. John's emergency department workers' concerns about physician staffing levels and patient safety, noting that doctors have sometimes been responsible for over 20 beds at a given time and "patients routinely had a 16-hour wait time in the emergency department."

A TeamHealth spokesperson told MedPage Today in an email that in 2023, "the median door-to-doctor wait time was 25 minutes and, in 2024, that has declined to 17 minutes," and physician staffing levels at the hospital "are higher than published medians for comparable emergency rooms across the country."

He also said that TeamHealth "has not balance billed patients in its 44-year history, keeping patients out of the middle of any dispute with an insurer for underpayment."

Peters' and its former owner KKR said that while the private equity company no longer owns the staffing firm, "its bankruptcy and restructuring raise questions about its impact on patient care." He specifically pointed to staffing issues at Tucson Medical Center and Chandler Regional Medical Center in Arizona.

A spokesperson for Envision said in an email that the company "intends to work transparently with Sen. Peters on his request" and that its "number one priority is always the well-being of our clinicians and the patients they serve."

In his and Apollo Global Management, Peters raised concerns about physician staffing levels and patient safety, noting that "while USACS is technically a 'physician-owned company,' its financial arrangement with Apollo is substantially different from traditional physician-owned emergency medicine groups and raises questions about physicians' clinical independence."

A spokesperson for USACS said the company is "confident our physician-owned model of care is in the best interests of patients, physicians, and hospitals."

Finally, the letter to Michigan-based Lifepoint Health and Apollo Global Management focused on physician staffing levels and emergency department wait times. Lifepoint Health did not return a request for comment from MedPage Today.

Overall, according to Peters, TeamHealth operates about 600 emergency departments across the country; Envision operates 440 emergency departments in the U.S., and USACS operates about 300 emergency departments in the country. Lifepoint Health owns more than 60 acute care hospitals.

Peters asked that the companies provide answers to his questions by April 17, and hold meetings with the committee by May 3.

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